Sir Aubrey Lewis by David Goldberg, Barry Blackwell and David Taylor

Although he described himself, aged 9, in an essay while in primary school as “an Australian, and my essay is from an Australian point of view 1”, Aubrey Lewis became the foremost psychiatrist in the United Kingdom of the 20th Century. He transformed psychiatry in Great Britain and produced a generation of academic psychiatrists; and he was directly responsible both for shaping the Maudsley Hospital from its early beginnings, and bringing about the existence of the Institute of Psychiatry as part of the University of London. He combined an encyclopaedic knowledge of world psychiatry with an exacting standard of scholarship. He did his utmost to ensure that each of his trainees achieved the highest standard of both clinical care and the results of their research. This paper will describe how he came to work at the Maudsley, and finally will outline some of his major achievements.

EARLY LIFE AND TRAINING

Aubrey Lewis was born in Adelaide in 1900. His father earned a living in the 1890s in a small watch-making and repairing business and his mother was a prize-winning local teacher of elocution. In view of his later achievements it is of interest that he could not read until he was 7, nor was it financially possible for his parents to send him to the school of their choice. It is possible that his development was delayed because his parents would have been advised that he should avoid eye-strain following an attack of measles. Once he started his reading, there was clearly no stopping him. He was educated at the Catholic Christian Brothers College in Adelaide, where he soon attracted the attention of his teachers. In competition at the age of 14 the judge specially complimented ‘Master Aubrey Lewis, who, without notes of any kind, discussed Shakespeare and his works with agreeable delivery and wonderful fluency’. In the following year, his teachers recorded the prophetic words that his discourse on the origin and history of words ‘exhibited a remarkable grasp of philology’ 1. His earliest interests were in literature, history and languages, so much so that the school teachers in his home town of Adelaide, Australia, predicted a distinguished career in the humanities 2. However, his early education formed a secure and lasting foundation for all his subsequent achievements.

During his years as a medical student at Adelaide Medical School he was a prominent member of the Medical Students' Society: “Mr. A. J. Lewis read his paper on 'Quacks', which proved to be one of the finest ever heard by the Medical Students' Society. His quick touches of humor, quiet sarcasm, balanced judgment, and above all, the brilliant style in which it was written, only go to show how great has been Medicine's gain, and I hope this will not prove to be literature's loss” 1 .

After house jobs in Adelaide his first piece of research was an anthropological study of the aborigines of South Australia which included their physical measurements, their implements, songs, vocabulary and psychological observations. Later that year he was awarded a Rockefeller medical research travelling fellowship for ‘study in psychological medicine and nervous diseases, with the special object of training the holder for studying the mental traits of the Australian aborigine'. He spent the next two years, in North America working with Adolf Meyer at Baltimore, in London at Queen Square with Gordon Holmes and in Germany, at Heidelberg with Karl Beringer and at the Charité in Berlin with Karl Bonhoeffer. On a brief return visit to Australia it became clear that there were no appropriate opportunities for him at home, and the Rockefeller Foundation allowed him to change from psychology to psychiatry and return to London.

After a brief spell at the National Hospital for Nervous Diseases in Queen Square, in 1928 he applied for a job as a sleep researcher at the Maudsley Hospital, which had opened in 1923 under the direction of Dr. Edward Mapother. A British University Hospital had been the dream of Henry Maudsley, who had hoped to create a university psychiatric hospital similar to that founded by Emil Kraepelin in Munich. Mapother had served in the British Army in the First World War, and Lewis expected from what he had been told that at the Maudsley he might have to re-adjust his modes of thought to a somewhat insular, rigid materialistic and old-fashioned model, of which Mapother would be the exponent. In fact, he found it quite otherwise 3.

Mapother was concerned that research in the UK was carried out by clinicians in their spare time. This led to an unduly optimistic outlook and prevented “the laborious observation and expeiment that forms the basis of every progressive science”. He avoided a rigid adherence to any school of thought and firmly believed in the advance of knowledge through empirical research. He believed in the importance of hard facts, and disapproved of cross-discipline speculation about causation and the meaning of symptoms. He had a skeptical attitude to new treatments, thinking that a doctor’s first duty was to do no harm, and distrusting new treatments for whose efficacy there was insufficient evidence. This aspect of psychological medicine was regarded as ‘spookery’, and thought not to be an appropriate activity for psychiatrists.

Mental phenomena, or the immediate products of perception were the only objects of knowledge. Where classification was concerned, manic-depressive psychosis was designated a provisional group of heterogeneous disorders, the neurotic-psychotic dichotomy was dismissed as meretricious; and the links between depression and such feeling-states as anxiety and phobias were admitted. Whilst Aubrey obviously felt at home and compatible with Mapother’s views, he also brought to the subject additional dimensions of benevolence, creativity, innovation and calculated risk taking. That opinion is shaped partly by personal experience of one of us (BB):

Lewis moved me from the B to the A stream, kept me under surveillance for 6 months and then gave me the opportunity of a lifetime, to work under Ted Marley with the only proviso that I was not to engage in psychoanalysis! While the Medical Director of SKF described the cheese idea as “unscientific and premature”, Aubrey reminded me that Hippocrates “had said something about cheese”. The quotation I found about why “cheese was a bad article of food” became the prelude to my Cambridge M.D. thesis.

Shortly after Lewis was appointed, Mapother was sent on a tour of major centers in the USA by the Rockefeller Foundation, and like Lewis before him was impressed by the psycho-biology of Adolf Meyer at the Johns Hopkins Hospital in Baltimore 2. Meyer insisted on thoroughness in history taking, in probing the family and social background, and Aubrey clearly agreed with him.

At the time of his arrival the Maudsley Hospital was small scale, so that the entire clinical and scientific staff could sit round a small table for lunch. However, by 1931 staff numbers had risen to 152 [including 17 permanent doctors], looking after 207 beds 2. Lewis became a consultant in 1932, and Clinical Director of the Maudsley by 1936 – the same year that Mapother was appointed the first Professor of Psychiatry at the Maudsley. During the 1930’s the Maudsley hospital trained many of those who became well known later, such as Eliot Slater, Maxwell Jones, John Bowlby, William Sargant, Denis Hill, John Sutherland and Wilfred Bion.

In 1938, on the eve of World War II, Aubrey Lewis was commissioned by the Rockefeller Foundation to undertake a review of European psychiatry. He embarked on a six month journey during which he visited 13 countries, 45 cities and interviewed 234 individual clinicians and research workers in a wide variety of settings; clinics, Institutes, hospitals, asylums, laboratories and prisons.

From this he produced a tour de force that was 90 pages long4. The report was archived unedited by the Foundation and not published until 65 years later when it was reviewed in an accompanying article 5, which comments “while Lewis was sent to the Continent to gain the perspectives and knowledge that would help to make the Maudsley a more impressive candidate for Rockefeller patronage, his disappointments and criticisms perhaps indicate a desire on his part to take Continental psychiatry down a peg or two and dispel what certainly Lewis deemed a myth of excellence. Of course it may simply be that Lewis’ criticisms reflect the character traits that later led to his reputation as someone who spoke the truth, regardless of the views of others or the inconvenience it might cause. What Lewis’ report very neatly reflects is a discipline in flux, whose membership was being worked out in a way that would shape the field’s development. It was lucky that Lewis, a notoriously frank man, shared the Foundation’s fundamental orientation and skepticism over certain branches of the field”.

Lewis concluded his report with a four page summary of his impressions. He starts by noting that most of the good things he found were in related branches of medicine, neurology, physiology and biochemistry. “Psychiatry seemed everywhere a rather stagnant subject”. Research activity was “flawed by conflicting results, weak technique, idea-less repetition, excess of speculation or – probably most important of all – failure to see problems that are at once fruitful and attackable. Certainly the fruits of psychiatric research seem very meager in relation to the volume, it is depressingly less alive and (intellectually if not practically) less exciting than some other branches of medicine.” In addition, psychiatry remained “outside the mainstream of medicine” while “the predominance of neurology and the extravagances of some psychotherapists seemed to have an almost equal share in delaying the social and psychological side of psychiatry”. To the recent reviewers this synopsis was “rather like a torchlight beam illuminating a previously dark corner.2 ”

He also addressed the way young psychiatrists were being taught: “little clinical acumen was displayed in assessing the outcome of treatment, the research possibilities were generally ignored and there was a risk that, as with psychotherapy, over-enthusiasm might in time provoke an excessive disillusionment”. He found that the standard of clinical work and knowledge was perceptibly lower in psychiatry than in neurology. “People often had a very detailed knowledge of the literature and difficulties of some tiny problem that they had worked on for a dissertation or article, but they had a poor grasp of clinical psychiatry as a whole; partly, I think, because they had not time to examine all their cases thoroughly, and because they were unduly satisfied with text-book accounts and needlessly conversant with bygone controversies….they were a little right and a little wrong: names of people and of categories and quarrels usurped the place of immediate experience” (italics added). Lewis was to return to these problems in his work as an educator after the end of the War. One can also see in these comments where his own future efforts might lie; with the application of stringent empiricism in carefully crafted studies on fruitful topics coupled with a devotion to strengthening psychiatry’s ties to medicine and the inclusion of psychological and social influences on outcome.

The Maudsley Hospital was moved out of London in 1939 because of the Blitz from the Luftwaffe, thus providing Lewis with a respite to contemplate the lessons learned from his 1938 European trip, and to integrate them with his own bent toward social psychiatry. He became Director of the Mill Hill Emergency Hospital treating servicemen, especially those with ‘effort syndrome”. This led to the first psychosocial treatment for this debilitating condition, from which Maxwell Jones developed into his concept of the ‘therapeutic community’.

Mapother had launched an appeal for an Institute of Psychiatry to be attached to the University of London in 1931, but never lived to see it come about, as he died in 1940.

THE CONTRIBUTIONS OF AUBREY LEWIS

In 1946 Lewis was appointed as Professor of Psychiatry at the Maudsley Hospital, but opted not to combine this with medical superintendent of the hospital, but to confine himself to teaching and research, and to be in charge of a professorial unit admitting its own patients. With the arrival of the NHS in 1948, the Maudsley was united with the Bethlem Royal Hospital, giving access to its rich endowment funds, and greatly expanding the number of beds available to what became the Joint Hospitals. He finally persuaded the University of London to adopt the Institute of Psychiatry (IoP) as part of the University of London in 1948, so that Henry Maudsley’s dream became a reality. He also obtained funds from the Medical Research Council to support what became the MRC Social Psychiatry Research Unit, with Lewis as its Director. In addition to the psycho-pharmacologists mentioned in our companion article 6, he ensured that the staff of the Institute included neurophysiologists, neuropathologists, biometricians and clinical psychologists.

1. Lewis as an educator of a generation of future academic psychiatrists

At the Maudsley Hospital, Lewis ensured that the psychotherapy department contained a wide range of approaches to psychological treatments, and did not become dominated by one particular school. On one’s first day, one was advised not to read a textbook, but to confine one’s reading to scientific papers – an echo of Aubrey’s pre-war complaint about European psychiatry.

As a clinical teacher, Lewis insisted on a carefully taken, detailed clinical history, and he was well known for interrupting junior doctors if they asserted something which they could not justify. “Are you sure that you asked the right question?” he might ask, and begin to drum his fingers on the desk. As a result many found his manner intimidating, and all his trainees would agree with Anthony Storr’s comment ‘that once you had presented a case to him, no other public encounter, be it with a large audience, in a TV studio or a lecture platform, could hold any terrors for you’. Although he did not intend to terrify us, he most certainly did so.

In one anxiety filled journal club presentation by an Australian registrar on the Burgholzli Centenary, Lewis asked him ‘how he could possibly know what Bleuler was thinking?’: only to discover that he had flown to Zurich at his own expense and spoken with Bleuler in fluent German! This illustrates the lengths residents sometimes went to meet his expectations, their caliber and the climate that he created while still allowing us to talk back.

Nor was the Journal Club the only ordeal: the Friday Case demonstration also inspired anxiety in the trainees:

His teaching methods were rigorous in the extreme. All the registrars had to be present while one of them presented his case to the Professor. This had to be done from memory without recourse to case notes. After this the wretched registrar was subjected to a searching cross-examination, spiced with sarcasm and devastating wit. Sir Aubrey clearly believed that in order to keep his students on their toes, it was best to ensure they were trembling in their boots. For all that he was an inspiring teacher 7.

Dr. D.L. Davies, who served as the Dean, wrote that “training at the Maudsley had connotations that were partly positive and partly negative. It is not a place that is dominated by too many psychoanalytical or cognate speculations or theories. People recognize this characteristic and regard it therefore in a sense as hard-headed, perhaps hypercritical, perhaps skeptical, but not pie-in-the-sky or ethereal. On the positive side I should think empirical methods strengthened by the results of research which enable theory to be formulated and eventually applied to practice. But I think it's chiefly in the balance that is observed in Maudsley psychiatry” 1. There were definitely aspects of the Maudsley that irritated and alienated reputable voices elsewhere in world psychiatry with misunderstandings that persist even today. An example would be controversies over lithium 8, and the lithium controversy 9.

In his paper on the Education of Psychiatrists 10, Lewis argues strongly for an all-purpose psychiatrist. ‘When he is asked to treat a child, to report on a criminal, to explain the origins of a strange symptom, to supervise a course of insulin, to diagnose a high grade defective, or to avail himself of the results of psychological tests, he should not have to choose whether he will excuse himself …. The psychiatrist, like other specialists, must acquire knowledge, some technical skill and an attitude for what he has to do…. He may, it is true, become an administrator, or a psychoanalyst, or a forensic expert, or even a professor – very diverse activities, but all requiring a broad training’. He saw the primary task in psychiatric education being to train a future generation of teachers.

Until about 1980, it remained true that most of those appointed to the proliferating Chairs of Psychiatry in the years following WWII had trained at the Maudsley. The teaching of Psychiatry to medical students was thus indirectly due to Lewis, and this also due to the new generation of consultant psychiatrists coming from the Maudsley to British Medical Schools. These teachers had themselves been taught a disciplined discourse rather than been left to create their own from reading and observation. Even into the late 1950’s medical student experience was of visits to various “Lunatic Asylums” where “residents” were shown on stage while a garbled account of their problematic behaviors was given by the resident doctor. Such displays, naturally, alienated students who might otherwise be drawn to the subject.

2. Research in social psychiatry

In 1935, Lewis had published a paper in Lancet on neurosis and unemployment 11 which argued that these men were social as much as medical problems, and one should aim at occupational as well as social interventions. He returned to this theme in 1944 from his position at Mill Hill 12.

After becoming Director of the MRC Unit in social psychiatry, he was responsible for the pre-eminent position of the United Kingdom in this field for the next 30 years or so, until new technology directed attention to genetics and neuro-imaging. Men such as Jack Tizard, Neil O'Connor, John Wing, Michael Rutter, Kenneth Rawnsley, Morris Carstairs, and Peter Venables worked for him at the MRC Unit. John Wing and George Brown also worked on the Unit, and made important contributions to the substantial body of knowledge that emerged from these important formative years. Lewis’s contribution was to ensure that research findings were factual, used reproducible methods of assessment and included social measures.

The high water mark of these especially productive years was the book on Institutionalism and Schizophrenia 13, which was the first formal demonstration that the phenomena of schizophrenia were not the immutable manifestations of some inner disease process, but were partly a product of the mental hospital environment.

3. The value of his papers on various subjects

On the occasion of Aubrey Lewis’ retirement in 1966, the members of the Junior Common Room undertook to gather together and edit a selection of his papers. In their introduction, they say “for his past students, now scattered throughout the world, these essays will, we hope, be something more: refreshing reminders of their training. For athletes training involves not only a gain in muscular strength, but a loss of excess fat. For psychiatrists Professor Lewis provided its intellectual equivalent. It has been through his teaching, with its challenging mixture of scholarship and common sense, that his influence has been most widely felt, and it is this which we, his present students, gratefully commemorate 14,15. In his review of the collected papers the writer says ‘Sir Aubrey wears his scholarship lightly, never writes like a pedant, never descends to jargon yet is never far from that perceptive wit which always lay beneath the surface of his quite remarkable mind even in its most earnest deliberations’ 16. Lewis' commitment to empiricism was essential and profound - he took an unsentimental (but not overtly unkind) view of how to determine the truth and conveyed this in perspicacious, pithy, elegant prose. In addition he was not (at least in his later years) preoccupied with his own reputation - either enhancing it or placing it in hazard by speaking the truth as he saw it.

We will here give examples of some of Lewis’ more important papers. His early papers on melancholia 17,18 report an exhaustive descriptive study of 61 patients with depression. Lewis states that his findings have ‘compelled divergence from the accepted views, as expressed in textbooks and monographs’, and the validity of [what were] accepted views on the classification of depression. Lewis describes paranoid features, the patient’s attitude to his environment, the various manifestations of retardation, anxiety and compulsive phenomena in depression. In these papers Lewis shows his almost encyclopaedic knowledge of the history of psychiatry – undoubtedly helped by his ability to read papers in both French and German in the original language. He fails to confirm the various groupings described by his predecessors, and takes the view that there are no independent disease entities, but rather an overlapping set of clinical phenomena which defy easy grouping, but are affected by the patient’s personality and social adjustment.

His views are best expressed in the section on Psychological Medicine in Price’s Textbook of Medicine 19. In this he compresses the whole of psychiatry into less than 60,000 words of clear, pithy prose, in an attempt to influence a generation of medical students. He gives his own views about the classification of affective disorders, asserting that there are three forms, each existing in a major and a minor form: manic excitement and hypomania; melancholia and ‘neurasthenic’ depression; and agitated depression and anxiety state. There are no rigid distinctions between each major and minor form, and in the third form he denies that there are clear distinctions to be made between depressive and anxiety states.

Having excited the interest of a medical student reading his section, the thoughtful student might go on to some of his more profound general papers, from which we will select only two. In ‘Health as a Social Concept’ 20 he argues that health is a single concept: it is not possible to set up essentially different criteria for physical and mental health. We commonly assume a continuum between health and ill-health, for which there is no counterpart in the phenomena but which we cannot yet replace by a continuum since we lack the means of measuring some of the necessary dimensions. There are three criteria for any medical illness: the patient feels ill, a general, subjective datum; he has some abnormality of a part-function, a restricted objective datum; and he has symptoms which conform to a recognizable clinical pattern, a typological datum. Social criteria play no part. The criterion of health is the adequate performance of functions, physiological and psychological. While our estimate of the efficiency with which functions work must take account of the social environment which supplies stimuli and satisfies needs, the criteria for health are not primarily social: “it is misconceived to equate ill-health with social deviation or maladjustment”.

In “Between Guesswork and Certainty in Psychiatry” 21 Lewis argues that “it is the common state of reflective and enquiring minds to be somewhere between untrammeled guesswork and certainty. It would be discreditable if psychiatrists were to be huddled at either extreme, wholly engaged in guessing, or ignorantly certain”. He goes on to consider why psychiatrists have been suspected of luxuriant speculation or invincible faith in our tenets. At the time one of us (DPG) was reading widely round the subject, and was finding a huge discrepancy between some of the wilder psychological explanations of symptoms I found in psycho-analytic books, and the dogmatic assertions of my undergraduate teachers at St Thomas’ Hospital. I found great comfort in this article, and decided that if there were brains like these writing in psychiatry, I had better leave my teaching hospital and relocate to the Maudsley. I found to my surprise on my arrival that there were more junior doctors from St Thomas’ than from all other London teaching hospitals combined. Perhaps this reflects William Sargant’s enthusiasm for the subject, suggesting to his students that mental disorders were very similar to physical illnesses, and all responded easily to energetic physical treatment.

We knew Professor Lewis in the closing years of his life, when early Parkinson’s Disease was making his face a mask, and his voice a monotonous whisper. The death of his wife had been a devastating blow, and he shrank visibly after that. The oratorical feats of his early life were no longer possible for him, but his mind was still razor-sharp, and his knowledge of the subject detailed and precise. He had encouraged his colleagues at the Institute to undertake research in metabolic aspects of psychiatry, in genetics using twin studies, in the common mental disorders encountered in primary care, and as we mention in our companion article, in psychopharmacology –– but he did not carry out research in these areas himself. Above all, the ‘remarkable grasp of philology’ noticed by his school teachers never deserted him – he was easily the most scholarly psychiatrist that we have ever encountered.

2. Jones E. 2003. Aubrey Lewis, Edward Mapother and the Maudsley, in In Ed. Angell K, Jones E, Neve M. Aubrey Lewis, the Maudsley Hospital and the Rockefeller Foundation in the 1930ies. European Psychiatry on the Eve of War. Medical History, Supplement No 23. Medical History, Supplement No 23. [Also London, Wellcome Trust Centre for the History of Medcine at UCL].

3. Lewis A. (1969). Edward Mapother and the making of the Maudsley Hospital.British Journal of Psychiatry 115, 1349-1366.

4. Lewis A. (2003) Report on Visits to the Psychiatric Centres in Europe. In Ed. Angell K, Jones E, Neve M. Aubrey Lewis, the Maudsley Hospital and the Rockefeller Foundation in the 1930ies. European Psychiatry on the Eve of War. Medical History, Supplement No 23. Also London, Wellcome Trust Centre for the History of Medicine at UCL.

5. Angell K (2003) Defining Psychiatry: Aubrey Lewis’s 1938 Report and the Rockefeller Foundation. In Ed. Angell K, Jones E, Neve M.. Aubrey Lewis, the Maudsley Hospital and the Rockefeller Foundation in the 1930ies. European Psychiatry on the Eve of War. Medical History, Supplement No 23. Also London, Wellcome Trust Centre for the History of Medicine at UCL.

All three authors began psychiatric training at the Maudsley Hospital and Institute of Psychiatry in 1962 as registrars (residents). All went on to fill department chairs in Britain and America. Sir David Goldberg became Director of the Institute and like his predecessor was knighted by the Queen. They have remained friends and colleagues since, now all retired.